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Advanced Rehabilitation, LLC, Irby Spine v. Unitedhealth Group

March 17, 2011

ADVANCED REHABILITATION, LLC, IRBY SPINE CENTER,PC AND SHORE SPINE CENTER & PHYSICAL REHABILITATION, PC, ON BEHALF OF THEMSELVES AND OTHERS SIMILARLY SITUATED PLAINTIFFS,
v.
UNITEDHEALTH GROUP, INC., UNITED HEALTHCARE, UNITED HEALTHCARE INSURANCE COMPANY, UNITED HEALTHCARE SERVICE, LLC, OXFORD HEALTH PLANS 9NJ0 INC., AND OXFORD HEALTH INSURANCE, INC. DEFENDANTS



The opinion of the court was delivered by: Hon. Dennis M. Cavanaugh

DENNIS M. CAVANAUGH, U.S.D.J.

OPINION

This matter comes before the Court upon motion to dismiss by United Healthcare et al ("Defendants") pursuant to Fed. R. Civ. P. 12(b)(6). Pursuant to Fed. R. Civ. P. 78, no oral argument was heard. After considering the submissions of the parties, and based upon the following, it is the decision of this Court that Defendants' motion to dismiss is granted.

I. BACKGROUND

This putative class action law suit is brought by four chiropractic providers, all of whom are

out of network providers under the terms of health insurance plans managed by Defendants. Defendants administer health plans for numerous employers and governmental entities. The plans at issue in the instant complaint are New York State Health Insurance Program/Empire Blue Cross-Blue Shield ("NYSHIP/BC-BS"), the Verizon/United Healthcare plan ("Verizon"), a plan administered on behalf of employees of the Port Authority of New York and New Jersey (PANYNJ), and an Oxford/Freedom Health Plan. The complaint alleges that each of the Plaintiffs performed a procedure known as manipulation under anesthesia ("MUA"), and that each was denied reimbursement because Defendants have a "blanket policy of denying coverage for MUA procedures" (ECF Doc. 32, page ID 1286) either on the grounds that the procedures are not medically necessary, at least for treatment of specific conditions, or that they are experimental for treatment of certain conditions. Plaintiffs also aver that the appeals process is "preordained to deny coverage." (ECF Doc. 32, page ID 1290). Each of the four chiropractic providers submitted claims on behalf of a patient who had been treated with MUA, and in each case the claim was denied, both initially, and through the subsequent appeals process. Plaintiffs raise claims under ERISA and State Law for breach of contract and breach of fiduciary duties, and request declaratory judgment and a permanent injunction enjoining Defendants from automatically denying coverage for MUA procedures.

II. LEGAL STANDARD 12(b)(6) Motion to Dismiss

In deciding a motion to dismiss pursuant to Fed. R. Civ. P. 12(b)(6), all allegations in the complaint must be taken as true and viewed in the light most favorable to the plaintiff. See Warth v. Seldin, 422 U.S. 490, 501 (1975); Trump Hotels & Casino Resorts, Inc., v. Mirage Resorts Inc., 140 F.3d 478, 483 (3d Cir. 1998). If, after viewing the allegations in the complaint in the light most favorable to the plaintiff, it appears beyond doubt that no relief could be granted "under any set of facts which could prove consistent with the allegations," a court shall dismiss a complaint for failure to state a claim. See Hishon v. King & Spalding, 467 U.S. 69, 73 (1984).In Bell Atl. Corp. v. Twombly, the Supreme Court clarified the Fed. R. Civ. P. 12(b)(6) standard. See 550 U.S. 544, 555 (2007). Specifically, the Court "retired" the language contained in Conley v. Gibson, 355 U.S. 41 (1957) that "a complaint should not be dismissed for failure to state a claim unless it appears beyond doubt that the plaintiff can prove no set of facts in support of his claim, which would entitle him to relief." Bell, 550 U.S. at 558 (citing Conley, 355 U.S. at 45--46). Instead, the Supreme Court instructed that "[f]actual allegations must be enough to raise a right to relief above the speculative level."Bell, 550 U.S. at 555-56.

III. DISCUSSION

The relevant portions of the health plans at issue are summarized below.

A. NYSHIP/BC-BS

The NYSHIP/BC-BS plan(see Def. Exhibit 1, page 59-61, ECF Doc. 30-3) in pertinent part, states the following under the heading "Limitations and Exclusions:" You are not covered for benefits by Empire Blue Cross Blue Shield...when any of the following apply to you (2) care must be medically necessary . Medically necessary care is care which, according to Empire Blue Cross Blue Shield criteria, is * consistent with the symptoms or diagnosis and treatment of your condition, disease, ailment or injury; * in accordance with generally accepted medical practice; * not solely for your convenience or that of your doctor or other provider; * the most appropriate supply or level of service which can be safely provided to you.

[E]mpire Blue Cross Blue Shield's determination of medical necessity will be made after considering the advice of trained medical professionals.

(12) Empire Blue Cross Blue Shield will not cover any treatment, procedure, drug, biological product or medical device (hereinafter "technology") if, in our sole discretion, it is not medically necessary in that such technology is experimental or ...


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